Insurance FAQs

Disputed Claims

Yes. Spouses of federal annuitants are covered under a family enrollment in the Federal Employees Health Benefits (FEHB) Program during the divorce process and during a legal separation. Spouses of annuitants lose eligibility for FEHB coverage when the divorce is final. Former spouses of annuitants can apply for coverage in the FEHB Program under the Spouse Equity or Temporary Continuation of Coverage provisions of the FEHB law. Former spouses of annuitants must contact the annuitant’s retirement system within 60 days after the divorce to apply.
For more information on divorce after retirement, please visit http://www.opm.gov/insure/health/faq/divorce.asp.

There are a number of factors for you to consider if you are employed part-time. Although you will not be eligible for the full government contribution, your entire employee contribution will be pre-tax if you participate in premium conversion. That larger reduction in taxable income might offset the lower government contribution. If you are a part-time reemployed annuitant, we suggest that you consult your agency or a qualified tax advisor to review your individual situation.

When you return to work after a break in service of less than 180 days, your human resources office will automatically enroll you in the same coverage that you had before you left your prior position. You will have to qualify to elect other coverage (Open Season, physical exam or life event).
When you return to work after a break in service of 180 days or more, your human resources office will automatically enroll you in Basic and the same Optional insurance that you had in your prior position. You will have this coverage the first day you are in pay and duty status. Any previous waiver of insurance is automatically cancelled. Unless you file a new waiver, Basic insurance becomes effective your first day in pay and duty status in a position in which you are eligible for coverage.
You may elect more insurance (if you don't already have the maximum) within 31 days of returning to service in an eligible position, regardless of the coverage you had during previous employment. If you do not make a new election, you will automatically get back whatever Optional insurance you had immediately before your separation. Any coverage that you had previously waived will be waived again.

If your agency does not pay your premiums, you must pay the employee's share of the premium during the first 12 months of coverage (just as any other employee on leave without pay). You must pay both the employee and government shares, plus an administrative charge of 2 percent of the total premium, for up to 12 additional months that you continue your coverage while on military duty.

The formulary for your health plan provides a list of medications that a team of health care specialists have approved. Your doctor will write a prescription based on your medical needs, but the formulary provides him with recommendations from the pharmacist and physician team.
An effective formulary system provides a medication safety feature. When drugs and administration methods are systematically included (or deleted) in a controlled drug formulary, there are a number of benefits. For instance, each new drug added undergoes a peer review process that uncovers any safety concerns with the drug. Also, when drugs are systematically added to the formulary, there is adequate time to educate the staff before the drug is used. An organized formulary also ensures that the number and variety of drugs is kept to an effective minimum. There are approximately 13,000 prescription drugs on the market today and several drugs can often be used to treat the same condition. A formulary, based on safety and cost considerations, helps to limit the drugs recommended by your plan's health care professionals.

We have published a final regulation that allows current FEHB annuitants and former spouses who are eligible for these programs to suspend their FEHB coverage and premium payments. The regulation allows these individuals to reenroll in the FEHB Program during the Open Season, or immediately if they are involuntarily disenrolled from the non-FEHB coverage.

If you remarry before age 55, your health benefits enrollment will end on the last day of the month preceding the month in which you remarry. However, if you were married for 30 years or more to the deceased employee or annuitant, your health benefits enrollment will continue. If you are enrolled in Self and Family coverage when your annuity ends, the enrollment will continue for any eligible children as long as one of them is entitled to receive a survivor annuity (but you will not be covered).

If you are on a deferred retirement annuity, you are not eligible for FEDVIP.
If you are retiring with title to an MRA+10 annuity and you postpone receiving your annuity, you are eligible for FEDVIP only when you begin to receive that annuity. You would not be eligible for FEDVIP during the time between your separation from duty and before actual receipt of your annuity.

Pay-As-You-Go
Under the Pay-As-You-Go option, you pay your share of the FEHB premium directly to your employing agency while on LWOP. These payments will generally be made with after-tax monies, since there is no pay from which to make deductions. Catch-Up
Most employees who have a period of LWOP choose to pay their FEHB premiums via the Catch-up option. Under this option, the agency remits your share of the FEHB premium to OPM while you are on LWOP. You incur an obligation to your employing agency and are required to repay it upon your return to pay status. The repayment of the amount owed will be treated on a pre-tax basis, if it's deducted from pay and you participate in premium conversion at the time the deduction is made. If you choose to repay the amount owed to your agency directly out-of-pocket your taxable income is not reduced.
Prepay
Your agency may (but is not required to) offer you the option to prepay your FEHB premium from salary before you go on a period of LWOP. The amount of FEHB premiums you prepay in advance may either be deducted from your pay or paid directly "out-of-pocket" to your agency. Payments made "out-of-pocket" do not reduce taxable income. The amount of FEHB premiums that you prepay will be treated on a pre-tax basis, if it is deducted from your pay and you participate in premium conversion. IRS rules limit the amount you may prepay on a pre-tax basis. If your period of LWOP will span two tax years, the amount that you may prepay on a pre-tax basis may not exceed the amount of FEHB premiums due for the remainder of the current tax year. If you wish to prepay the amounts due for the subsequent tax year as well, the deductions must be made after-tax. You may use the "Pay-As-You-Go" or Catch-up options for amounts due in the subsequent tax year.
ExampleSam A. participates in premium conversion and had $100 per month in FEHB premiums deducted from his pay. He will go on LWOP for three months beginning on October 31, 2002 and opts to continue his FEHB coverage. Mr. A. uses the pre-pay option to pay from his salary the $300 in FEHB premium payments that will be due while he is on LWOP. Mr. A. will receive pre-tax treatment for only $200 of his FEHB premium prepayment- the amount he will owe for the months of November and December 2002. The remaining $100 prepaid – the amount due for January 2003 – must be given after-tax treatment.

You are no longer an eligible family member when your divorce or annulment becomes final. You get a 31-day extension of your health benefits plans coverage after that date. You may convert to an individual contract offered by your health benefits plan, if you don't qualify for or don't want FEHB coverage through Spouse Equity or TCC.

Under CSRS offset, your Social Security benefits would be slightly reduced, but your CSRS Offset benefits would be increased by almost the same amount. Participating in premium conversion is most likely a benefit to you.

Life insurance Open Seasons are held quite infrequently, and you should not count on one occurring any time soon. You will receive plenty of notice if and when there is an Open Season. The most recent FEGLI Open Seasons were held from September 1 - September 30, 2004 and in 1999.

While you may count the time you are covered under transitional TRICARE toward meeting the 5 year/initial opportunity requirement to continue your FEHB into retirement, you must be covered under FEHB on the day you retire. If you plan to retire during your transitional TRICARE period, you must reinstate your FEHB before your retirement date. Your Human Resources Office can assist you.

The National Defense Authorization Act for 2001 (Act) extended TRICARE pharmacy coverage to uniformed services Medicare eligible retirees, spouses, and survivors on April 1, 2001. Now uniformed services beneficiaries can get comprehensive prescription drug coverage through TRICARE's retail, mail order, or military treatment facility pharmacies. The Act also reinstated eligibility for TRICARE medical benefits for these beneficiaries on October 1, 2001. Beneficiaries with Medicare Parts A and B are now eligible to use TRICARE coverage for physician, hospital, surgical, and pharmaceutical services.

If you disagree with the plan’s decision on your claim, the Federal Employees Health Benefits (FEHB) Program provides for an appeal process. Check your plans FEHB brochure to see if the service is covered, limited, or excluded.
Review and follow the directions in the disputed claims section (Section 8) of the brochure. This section will tell you how to ask the plan to reconsider your claim. You must explain why (in terms of the applicable brochure coverage provisions) you feel the services should be covered.
If the plan again denies the claim, read the plan's decision letter carefully. Then, check your plan's brochure again. If you still disagree with the plan's decision, the disputed claims section of the brochure will tell you how to write to the U.S. Office of Personnel Management to ask us to review the claim.
If you have a complaint that is not related to a disputed claim, email your complaint to FEHB@opm.gov.

Most health maintenance organizations (HMO) restrict enrollment to an area where its doctors and hospitals are accessible. Although some HMOs do not have restrictions on where you live or work, please recognize that if you later find it is inconvenient to get to a plan provider, you may have to wait until the next Open Season to change plans.